Severe Valvular Aortic Stenosis Research Articles

A rare case of ascending aortic stenosis

A 48-year-old woman was referred to an in-hospital cardiology evaluation after performing a transthoracic echocardiography (TTE) that indicated a severe aortic valvular stenosis. She had a cognitive delay, short stature and long-term symptoms of fatigue for moderate exertion. No history of syncope or angina. …

TCTAP C-119 PCPS Supported Successful PCI for Complex Coronary Artery Disease with High Surgical Risk: Poor LVEF, Severe Aortic Valvular Stenosis, Tight Left Main Stenosis with Triple Vessel Disease

### Patient initials or identifier number SSG ### Relevant clinical history and physical exam 60 years old male presented with sudden dyspnea, chest pain and syncope since 1 day ago. He was on hemodialysis since 1999 years, and on medication due to chest pain with suspicious RCA territory

The arterial blood pressure associated with terminal cardiovascular collapse in critically ill patients: a retrospective cohort study.

IntroductionLiberal and overaggressive use of vasopressors during the initial period of shock resuscitation may compromise organ perfusion and worsen outcome. When transiently applying the concept of permissive hypotension, it would be helpful to know at which arterial blood pressure terminal cardiovascular collapse occurs.MethodsIn this retrospective cohort study, we aimed to identify the arterial blood pressure associated with terminal cardiovascular collapse in 140 patients who died in the intensive care unit while being invasively monitored. Demographic data, co-morbid conditions and clinical data at admission and during the 24 hours before and at the time of terminal cardiovascular collapse were collected. The systolic, mean and diastolic arterial blood pressures immediately before terminal cardiovascular collapse were documented. Terminal cardiovascular collapse was defined as an abrupt (<5 minutes) and exponential decrease in heart rate (>50% compared to preceding values) followed by cardiac arrest.ResultsThe mean ± standard deviation (SD) values of the systolic, mean and diastolic arterial blood pressures associated with terminal cardiovascular collapse were 47 ± 12 mmHg, 35 ± 11 mmHg and 29 ± 9 mmHg, respectively. Patients with congestive heart failure (39 ± 13 mmHg versus 34 ± 10 mmHg; P = 0.04), left main stem stenosis (39 ± 11 mmHg versus 34 ± 11 mmHg; P = 0.03) or acute right heart failure (39 ± 13 mmHg versus 34 ± 10 mmHg; P = 0.03) had higher arterial blood pressures than patients without these risk factors. Patients with severe valvular aortic stenosis had the highest arterial blood pressures associated with terminal cardiovascular collapse (systolic, 60 ± 20 mmHg; mean, 46 ± 12 mmHg; diastolic, 36 ± 10 mmHg), but this difference was not significant. Patients with sepsis and patients exposed to sedatives or opioids during the terminal phase exhibited lower arterial blood pressures than patients without sepsis or administration of such drugs.ConclusionsThe arterial blood pressure associated with terminal cardiovascular collapse in critically ill patients was very low and varied with individual co-morbid conditions (for example, congestive heart failure, left main stem stenosis, severe valvular aortic stenosis, acute right heart failure), drug exposure (for example, sedatives or opioids) and the type of acute illness (for example, sepsis).Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0719-2) contains supplementary material, which is available to authorized users.

Impact of kidney function on mortality after transcatheter valve implantation in patients with severe aortic valvular stenosis

AimsTranscatheter aortic valve implantation (TAVI) is an accepted alternative for patients with severe aortic valve stenosis who cannot undergo surgery. Acute kidney injury (AKI) is a serious complication in any invasive cardiovascular intervention.The objectives of the study were to determine (i) the influence of kidney function before TAVI and (ii) the impact of changes in kidney function after TAVI, including acute kidney injury (AKI), on mortality. Methods and resultsA total of 540 patients undergoing TAVI were included. Patients were divided into three groups according to glomerular filtration rate (GFR) before TAVI (A: normal renal function i.e. GFR ≥60ml/min; B: impaired renal function i.e. GFR 30–59ml/min; C: severe impaired renal function i.e. GFR <30ml/min).Multivariate analysis showed a significant impact of GFR on mortality (p<0.0008). Subgroup analysis showed significant differences between the groups in 30-day (A: 5.4%, B: 9.0%, C: 25.0%) and 12-month mortality (A: 15.0%, B: 32.0%, C: 49%). Patients who had an increase in GFR after TAVI by more than 22% (p=0.0068) had an improved survival rate, whereas a decrease in GFR by more than 15% was associated with an increased mortality rate (p=0.0051). AKI occurred in 30 patients (5.6%), of which 22 patients (73.3%) died within 12months. ConclusionOutcome is significantly related to pre-procedural kidney function. In addition, changes in kidney function after TAVI have a significant impact on mortality. Due to a very poor prognosis in patients with AKI, any effort to prevent this serious complication after TAVI needs to be taken.

Hybrid balloon valvuloplasty through the ascending aorta via median sternotomy in infants with severe congenital valvular aortic stenosis: feasibility of a new method†

To evaluate a novel hybrid balloon valvuloplasty procedure for severe congenital valvular aortic stenosis in low-weight infants, performed through the ascending aorta via median sternotomy. Eighteen infants (<90 days of age) with severe congenital aortic stenosis were included in this study. Hybrid balloon valvuloplasty procedures were performed in a hybrid operating room. Patients were followed up at 3 months, 6 months, 1 year and then annually following the procedure. The hybrid balloon valvuloplasty procedure was successful in all patients. Eight patients were successfully rescued from left ventricular systolic dysfunction by cardiac compression under direct vision. The aortic valve pressure gradient decreased from 80.3 ± 20.8 mmHg preoperatively to 16.0 ± 3.6 mmHg immediately postoperatively (P < 0.001). None of the patients developed significant aortic insufficiency. The fluoroscopy time was 6.2 ± 2.9 min. Intraoperative blood transfusions and pacing were not required. The patients were all alive and healthy at the end of the follow-up period (mean 21.3 months; range 3-41 months), and the aortic valve pressure gradient remained low (21.7 ± 5.3 mmHg). Reintervention was not required in any of the patients. Hybrid balloon valvuloplasty through the ascending aorta via median sternotomy is an effective and safe procedure for infants with severe congenital aortic stenosis.

Dobutamine stress echocardiography: a review and update

Stress echocardiography is a noninvasive cardiovascular diagnostic test that provides functional and hemodynamic information in the assessment of a number of cardiac diseases. Performing stress echocardiography with a pharmacologic agent such as dobutamine allows for simulation of increased heart rate and increased myocardial physiologic demands in patients who may be unable to exercise due to musculoskeletal or pulmonary comorbidities. Dobutamine stress echocardiography (DSE), like exercise echocardiography, has found its pri- mary application in ischemic heart disease, with roles in identification of obstructive epicardial coronary artery disease, detection of viable myocardium, and assessment of the efficacy of anti-ischemic medical therapy in patients with known coronary artery disease. DSE features prominently in the evaluation and management of valvular heart disease by helping to assess the effects of mitral and aortic stenoses, as well as a specific use in differentiating true severe valvular aortic stenosis from pseudostenosis that may occur in the setting of left ventricular systolic dysfunction. DSE is generally well tolerated, and its side effects and contraindica- tions generally relate to consequences of excess inotropic and/or chronotropic stimulation of the heart. The aim of this paper is to review the indications, contraindications, advantages, disadvantages, and risks of DSE.

Surgical treatment of valvular and supravalvular aortic stenosis in homozygous familial hypercholesterolemia

A 61-year-old male with homozygous familial hypercholesterolemia presented with dyspnea and syncope. He had been treated with low-density lipoprotein apheresis for 26 years. Echocardiography and computed tomography showed severe valvular and supravalvular aortic stenosis. Computed tomography and cardiac catheterization revealed a severely calcified narrowed aortic root and an occlusion in the proximal right coronary artery. During surgery, the ascending aorta was replaced under deep hypothermic circulatory arrest without aortic cross-clamping. After that, the aortic root from the annulus to the sino-tubular junction was enlarged with a two-ply bovine pericardial patch. An aortic valve replacement with a 17 mm mechanical valve and coronary artery bypass grafting to the right coronary artery were performed. The patient recovered from the surgery without any cerebrovascular complications.

Aortic balloon valvuloplasty in corrected transposition of the great arteries with severe valvular aortic stenosis of congenital bicuspid aortic valve.

Aortic balloon valvuloplasty in corrected transposition of the great arteries with severe valvular aortic stenosis of congenital bicuspid aortic valve.

Clinical impact of paravalvular leaks on biomarkers and survival after transcatheter aortic valve implantation

There is accumulating evidence that up to 20% of the implanted devices after TAVI are associated with a significant degree of paravalvular leaks, which appear to be associated with a negative clinical outcome. A total of 355 patients with severe aortic valvular stenosis (AVS) were treated by TAVI (Corevalve n = 222, Edwards Sapien n = 133). Survival, NT-proBNP and the grade of PVL were quantified up to 12 months after implantation. Technical success rate was 97.8%. Thirty-day mortality was 9.6%. Post-procedural transvalvular aortic regurgitation was seen only in a minority of cases (5%), whereas PVL were frequently observed (grade: <1+ in 58.2%, ≥1-<2 in 33.9%, and ≥2 in 7.9%). There was a clear relation-ship between PVL and adverse outcome (P < 0.001). After a transient increase, NT-proBNP showed a significant decline. Interestingly, a PVL ≥2+ was associated with a much higher rise in NT-proBNP compared to the other groups (P < 0.01), and a post-procedural increase in NT-proBNP by more than 1640 ng L(-1) within 5 days was associated with a significant increase in rate of death (P < 0.01). TAVI is an efficient treatment option for high-risk patients with severe AVS. The incidence of PVL is an inacceptable clinical problem. Serial measurement of NT-proBNP can be used for risk-stratification in patients with a significant PVL. In general, PVL graded ≥2+ is associated with a dramatically increased 6-month mortality. Therefore, any action to reduce paraprosthetical regurgitation is highly recommended.

Combined severe valvular aortic and valvular pulmonary stenosis and its management – A case report and literature review

Isolated congenital valvular stenosis of either aortic or pulmonary valve is commonly seen yet the presence of both these lesions in the same patient is rare. This combination presents unusual diagnostic as well as management problems. Apart from a few case reports, there is little in the literature on the combined stenosis of both semilunar valves. We present here a case report of a three and half year old boy diagnosed as a combined congenital severe valvular aortic stenosis with valvular pulmonary stenosis. The patient underwent successful balloon dilatation of both these valves in the same sitting.

Demographics of severe valvular aortic stenosis in Singapore

The treatment of aortic valve stenosis (AS) is seeing renewed interest mainly due to the availability of transcatheter therapies. However, the number of epidemiological studies of this disease in Singapore is limited. We aimed to describe the aetiology and clinical presentation of AS in Singapore, as well as patients' attitudes toward it. Our findings may facilitate the future planning and utilisation of resources to better manage these patients. 249 consecutive patients who underwent transthoracic echocardiography (from April 1999 to April 2008) and diagnosed with severe AS were assessed. Demographic and clinical data were collected, and patients' decisions on surgery were determined. The mean patient age was 71 (range 23-98) years. 50.2% of patients were male. The commonest presenting symptom was dyspnoea, and 40 (16.0%) patients had coexistent atrial fibrillation. The aetiology of AS was degenerative in 216 (86.7%), rheumatic in 11 (4.4%) and related to a bicuspid valve in 22 (8.9%) patients. The average peak velocity across the aortic valve was 4.2 ± 0.8 m/s and the mean aortic valve area was 0.76 ± 0.13 cm2. The overall mean logistic EuroSCORE was 10.7 ± 12.3. 105 (42.2%) patients who were offered surgery refused. 87 (35%) deaths were seen during the follow-up period (mean duration 14.5 months), which also saw 68 (27%) patients undergo surgery and 86 (34%) patients hospitalised for heart failure. Degenerative AS was the commonest aetiology in this contemporary cohort of patients. Despite the known benefits of surgery, the refusal rate for surgery remained high.

Indications for Surgical Aortic Valve Replacement

The average survival rate was 3 years after the onset of angina pectoris in patients with severe Aortic Stenosis (AS) [1]. The average survival rate after the onset of syncope in patients with severe AS was 3 years [1]. The average survival rate after the onset of heart failure in patients with severe AS was 1.5 to 2 years [1]. Patients with symptomatic severe valvular AS have a poor prognosis [1-4]. At the National Institutes of Health, 52% of patients with symptomatic severe valvular AS not operated on were dead at 5 years [1]. At 10-year followup, 90% of these patients were dead. At 4-year follow-up of patients aged 75 to 86 years in the Helsinki Aging Study, the incidence of cardiovascular mortality was 62% in patients with severe AS [2]. At 4-year follow-up, the incidence of total mortality was 76% in patients with severe AS [2]. In a prospective study, at 19-month follow-up (range 2 to 36 months), 90% of 30 patients with heart failure associated with unoperated severe AS and a normal left ventricular ejection fraction were dead [3]. At 13-month follow-up (range 2 to 24 months), 100% of 18 patients with heart failure associated with unoperated severe AS and an abnormal left ventricular ejection fraction were dead [3]. In a prospective study, at 20-month follow-up of 40 elderly patients with severe AS, heart failure, syncope, or angina pectoris was present in 36 of 37 patients (97%) who developed new coronary events and in none of 3 patients (0%) without new coronary events [4]. Surgical Aortic Valve Replacement (AVR) is the procedure of choice for symptomatic patients with severe AS (an aortic valve area less than 1.0 cm 2 ) with a Class I indication [5]. Other Class I indications for AVR in patients with severe AS include 2) patients undergoing coronary artery bypass graft surgery, 3) patients undergoing surgery on the aorta or other heart valves, and 4) patients with a left ventricular ejection fraction less than 50% [5]. Patients with moderate AS undergoing coronary artery bypass graft surgery or surgery on the aorta or other heart valves have a Class IIa indication for AVR [5].

Percutaneous coronary intervention in TAVI candidates: a report of two cases

Coronary artery obstruction is a rare complication of transcatheter aortic valve implantation (TAVI). Bulky calcified aortic valve and ostial lesions of the coronary arteries are known risk factors for coronary artery obstruction. No consensus guideline has been proposed for treatment in these circumstances. We present two cases of patients with severe aortic valvular stenosis and concomitant left-main

Transfemoral and Transseptal Valve-in-Valve Implantation Into a Failing Mitral Xenograft With a Balloon-Expandable Biological Valve

Valve-in-valve implantation for degenerated surgical bioprosthetic valves is becoming an increasingly accepted approach in selected high-risk patients. In the past, valve-in-valve implantations have been mainly performed in aortic position and only rarely in mitral position. We describe the case of an 81-year-old female patient with severe mitral regurgitation of a degenerated Carpentier-Edwards biological prosthesis treated by transfemoral and transseptal implantation of a SAPIEN-XT valve.

Asymptomatic Left Ventricular Systolic Dysfunction in Patients With Severe Aortic Stenosis: Characteristics and Outcomes

This study sought to determine the prevalence, characteristics, and outcomes of asymptomatic left ventricular (LV) systolic dysfunction in patients with severe aortic stenosis (AS). Management of asymptomatic patients with severe AS remains controversial. In these patients, LV systolic dysfunction, defined in the guidelines as ejection fraction <50%, is a Class I(C) indication for aortic valve replacement (AVR), but its prevalence is unknown. A retrospective study of adults ≥40 years of age with severe valvular AS (peak velocity ≥4 m/s, mean gradient >40 mm Hg, aortic valve area [AVA] <1 cm(2), or AVA index <0.6 cm(2)/m(2)) from 1984 to 2010 was undertaken. Patients with prior cardiac surgery, severe coronary artery disease, or greater than moderate aortic regurgitation were excluded. Of 9,940 patients with severe AS, 43 (0.4%) patients had asymptomatic LV dysfunction. Age was 73 ± 14 years and 70% were male. Hypertension (78%) and LV hypertrophy (LV mass index 143 ± 36 g/m(2)) were characteristic. Fifty-three percent of these patients developed symptoms at 21 ± 19 months after diagnosis. During 7.5 ± 6.7-year follow-up, 5-year mortality was 48%. After multivariable adjustment, there was no survival advantage with AVR in asymptomatic, severe AS with LV dysfunction (p = 0.51). In severe AS, the prevalence of asymptomatic LV systolic dysfunction is 0.4%. Despite an asymptomatic clinical status, patients with severe AS and LV ejection fraction <50% have a poor prognosis, with or without AVR.

A Case of Aortic Stenosis and Hypertrophic Cardiomyopathy

A patient with severe aortic valvular stenosis and coexisting obstructive hypertrophic cardiomyopathy, in whom diagnostic difficulties and management dilemmas arose, is presented. The complex issues involved in such a combination are discussed.

Percutaneous aortic interventions in patients with severe valvular aortic stenosis

Percutaneous aortic interventions in patients with severe valvular aortic stenosis

Direct Percutaneous Access Technique for Transaxillary Transcatheter Aortic Valve Implantation: “The Hamburg Sankt Georg Approach”

This study questioned whether transaxillary transcatheter aortic valve implantation (TAVI) is feasible as a true percutaneous approach using percutaneous closure devices. Transaxillary TAVI is gaining increasing acceptance as an alternative to the transfemoral route; however, the access has always been done via surgical cutdown so far. Between August 2010 and September 2011, a total of 24 high-risk patients with severe aortic valvular stenosis underwent a percutaneous TAVI procedure by direct puncture of the axillary artery without surgical cutdown. For safety reasons and as a target for the puncture, a wire was advanced via the ipsilateral brachial artery. Moreover, a balloon was placed into the subclavian artery via the femoral artery for temporary vessel blockade before percutaneous vessel closure. Vascular closure was performed using either the ProStar XL system (Abbott Vascular Devices, Redwood City, California) or 2 ProGlide systems (Abbott Vascular Devices). The true percutaneous approach was successfully completed in all patients (14 left and 8 right axillary artery cases). Overall mortality at 30 days was 8.3%. Acute vascular closure device success was achieved in 17 patients (71%). Vascular closure device success rate was 100% for the ProGlide device and 37% for the ProStar device, respectively. Seven patients (29%) with failing closure devices were treated by endovascular stent graft implantation without the need for surgical repair. For the last 12 treated patients, direct closure was achieved in 11 patients. Direct puncture of the axillary artery for TAVI is feasible and safe if a wire is placed into the subclavian artery via the ipsilateral brachial artery.

Persistent Reduction in Left Ventricular Strain Using Two-Dimensional Speckle-Tracking Echocardiography after Balloon Valvuloplasty in Children with Congenital Valvular Aortic Stenosis

The aim of this study was to investige serial changes of myocardial deformation using two-dimensional speckle-tracking echocardiographic (2DSTE) imaging in children undergoing balloon valvuloplasty for congenital valvular aortic stenosis (VAS). Thirty-seven children with isolated congenital VAS were enrolled in this study prospectively. Patients underwent echocardiographic evaluation at three instances: before balloon valvuloplasty, 6 months after intervention, and 3 years after intervention. Longitudinal, circumferential, and radial peak systolic strain values were determined, as well as systolic strain rate and the time to peak global systolic strain. Linear mixed statistical models were used to assess changes in 2DSTE parameters after balloon intervention. Using one-way analysis of variance, 2DSTE results at 3-year follow-up were compared with 2DSTE measurements in 74 healthy age-matched children and 76 children with uncorrected VAS whose severity of stenosis corresponded to residual stenosis of study subjects at 3-year follow-up. Global peak strain and strain rate measurements in all three directions were decreased before intervention compared with healthy children. Global peak strain and strain rate measurements increased significantly (P < .001) several months after balloon valvuloplasty and continued to increase at 3-year follow-up. However, at 3-year follow-up, global peak strain and strain rate in the longitudinal and circumferential directions were significantly lower (P < .001) compared with both control groups. Measurements of time to peak global systolic strain were significantly shorter at early follow-up compared with measurements before intervention (P < .05). Shortly after balloon valvuloplasty for severe congenital VAS, there is an improvement in systolic myocardial deformation. However, 2DSTE parameters do not return to normal at 3-year follow-up. These abnormalities in systolic deformation cannot be fully attributed to residual stenosis or aortic regurgitation.

Sexual Activity and Cardiovascular Disease

Sexual activity is an important component of patient and partner quality of life for men and women with cardiovascular disease (CVD), including many elderly patients.1 Decreased sexual activity and function are common in patients with CVD and are often interrelated to anxiety and depression.2,3 The intent of this American Heart Association Scientific Statement is to synthesize and summarize data relevant to sexual activity and heart disease in order to provide recommendations and foster physician and other healthcare professional communication with patients about sexual activity. Recommendations in this document are based on published studies, the Princeton Consensus Panel,4,5 the 36th Bethesda Conference,6–10 European Society of Cardiology recommendations on physical activity and sports participation for patients with CVD,11–13 practice guidelines from the American College of Cardiology/American Heart Association14–16 and other organizations,17 and the multidisciplinary expertise of the writing group. The classification of recommendations in this document are based on established ACCF/AHA criteria (Table). View this table: Table. Applying Classification of Recommendation and Level of Evidence Numerous studies have examined the cardiovascular and neuroendocrine response to sexual arousal and intercourse, with most assessing male physiological responses during heterosexual vaginal intercourse.18–24 During foreplay, systolic and diastolic systemic arterial blood pressure and heart rate increase mildly, with more modest increases occurring transiently during sexual arousal. The greatest increases occur during the 10 to 15 seconds of orgasm, with a rapid return to baseline systemic blood pressure and heart rate thereafter. Men and women have similar neuroendocrine, blood pressure, and heart rate responses to sexual activity.24,25 Studies conducted primarily in young married men showed that sexual activity with a person's usual partner is comparable to mild to moderate physical activity in the range of 3 to …